Provider Demographics
NPI:1811125974
Name:BERGSTEDT, LARA M (LCSW)
Entity type:Individual
Prefix:
First Name:LARA
Middle Name:M
Last Name:BERGSTEDT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LARA
Other - Middle Name:M
Other - Last Name:CAMPBELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:3446 191ST ST
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:IL
Mailing Address - Zip Code:60438-3848
Mailing Address - Country:US
Mailing Address - Phone:708-837-8377
Mailing Address - Fax:
Practice Address - Street 1:323 W MULBERRY ST
Practice Address - Street 2:
Practice Address - City:WATSEKA
Practice Address - State:IL
Practice Address - Zip Code:60970-1568
Practice Address - Country:US
Practice Address - Phone:815-432-5241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-29
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLSW00000060901041C0700X
IN34008657A1041C0700X
IL149.0136071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical